Viral Hepatitis new.pptx

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    Viral HepatitisOleh :

    Yosin Guruh Herawati (09-024)Lidya Dinda Dwi D. (09-025)

    Meita Eryanti (09-026)

    Maya Nuswantari (09-027)

    Defi Krishartantri (09-031)

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    Patofisiologi Hepatitis A

    HVA yang terdapat pada makanan, dan air yang tekontaminasi masuk ke dalam

    saluran pencernaan

    Menuju hati(vena porta),lalu menginvasi ke sel parenkim hati.

    Di sel parenkim hati virus mengalami replikasi yang menyebabkan sel parenkim

    hati menjadi rusak

    . Sel parenkim yang telah rusak akan merangsang reaksi inflamasi akan

    menekan ductus biliaris sehinnga aliran bilirubin direk terhambat

    Bilirubin konjugasi(direk) akan terus menumpuk dalam sel hati yang akan

    menyebabkan reflux(aliran kembali keatas) ke pembuluh darah

    partikel bilirubin direk berukuran kecil sehingga dapat masuk ke ginjal dan di

    eksresikan melalui urin.

    Akibat bilirubin direk yang kurang dalam usus mengakibatkan gangguan dalam

    produksi asam empedu (produksi sedikit) sehingga proses pencernaanmenyebabkan timbulnya gejala mual, muntah dan menurunnya nafsu makan

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    Patofisiologi hepatitis B

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    Patofisiologi Hepatitis C

    VHC Masuk ke hepar

    Hepar

    rusak

    Salinan-salinan

    virus VHC

    (quasispecies)

    bereplikasi

    RNA-dependent

    RNA polimerase

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    Gejala & Tanda

    Hepatitis A Kulit dan mata menjadi kuning

    Sakit perut bagian kanan atas

    Hilangnya nafsu makan

    Mual & muntah

    Feses berwarna gelap

    Umumnya gejala ini munculnya 2-4 minggu

    setelah terinfeksi

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    Hepatitis B

    Akut

    Kulit dan mata menjadi kuning

    Sakit perut bagian kanan atas

    Hilangnya nafsu makan

    Mual & muntahFeses berwarna gelap

    Umumnya gejala ini munculnya 4-6

    minggu setelah terinfeksi

    Hepatitis B

    Kronik

    Bila sistem kekebalan tubuh

    tidak mampu mengendalikan HBV

    selama 6 bulan, maka gejala

    Hepatitis B kronis bisa muncul.

    Gejala = Hepatitis A.

    Namun gejala tambahan yang

    terjadi berupa ruam, urtikaria,

    peradangan sendi, dan

    polineuropati

    Gejala & Tanda

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    Hepatitis C

    Hilangnya nafsu makan

    Mual & muntah

    Demam

    Sakit kuning

    Hilangnya berat badan

    Sakit pada otot dan sendi

    Perut membuncit

    Umumnya gejala ini munculnya 5-8

    minggu setelah terinfeksi

    Gejala & Tanda

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    TREATMENT FOR HAV

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    DESIRED OUTCOME

    Complete clinical resolution

    Reducing complications from the

    infection

    Normalization of liver function

    Reducing infectivity and transmission

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    GENERAL APPROACH FOR

    TREATMENT No specific treatment option => general suporting care

    Patient who liver failure => transplantation liver

    Steroid use is not recommended!

    Prevention and prophylaxis

    Imunoglobulin => prophylaxis and passive immunity Vaccination => active immunity

    Prevaccination serologic testing to determinesusceptibility

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    PREVENTION HAV

    Routine prevention of HAV

    transmission includes regular hand

    washing with soap and water after

    using the bathroom, changing adiaper, and before food preparation.

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    Di AMERIKA..

    Vaccines to prevent HAV

    havrix

    Pake pengawet 2-phenoxyphenolantigen is expressed as ELISA

    units

    Vaqta

    Gak pake pengawetuses units of HAV antigen to

    express potency

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    Side effect:

    The most common: soreness and warmth at the

    injection site, headache, malaise, and pain.

    The serious adverse event: anaphylaxis, guillain-

    Barre syndrome, brachial plexus neuropathy,

    transverse myelitis,multiple sclerosis,

    encephalopathy, and erythema multiforme.

    THE VACCINE IS CONSIDERED

    SAFE!!!

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    Immunoglobulin

    Provides protection by passive transfer of antibody

    Most effective if given in the incubation period of theinfection (the first 2 weeks)

    Do not need for people who just received HAVvaccine

    Serious adverse events are rare => that may happen:anaphylaxis

    Postexposure prophylaxis

    short-therm preexposure

    coverage < 3 months

    A single dose of

    0,02 mL/kg I.M

    Deltoid or glutealmuscle

    Long-therm preexposure

    prophylaxis < 5 months

    A single dose of

    0,06mL/kg I.M

    Younger than 24 months Anterolateral muscle

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    Imunoglobulin.

    Can interfere with the response ofother vaccines (MMR and varicella)

    and should be delayed.

    In general, Ig doesnt interfere withinactived vaccines and may be

    administered safely with other

    vaccines.

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    TREATMENT FOR HBV

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    Desired outcome

    Increase the chances for

    seroclearance

    Prevent disease progression to

    cirrhosis and HCC

    To minimize further injury in patients

    with ongoing liver damage

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    General approach treatment

    Not all chronic HBV patients are candidates

    for treatment. Some patients may be best

    managed with periodic monitoring fordisease progression because the chances

    for therapeutic response are unlikely and do

    not outweigh the risk and costs associated

    with treatment.

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    TREATMENT FOR HCV

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    Desired outcome

    To eradicate HCV infection

    Even patients who are unable to

    achieve cure may see historical

    improvements with therapy.

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    General approach to treatment

    Treatment is indicated for patients

    previously untreated who have chronic

    HCV, circulating HCV RNA, increased ALT

    levels, evidence on biopsy of moderate tosevere hepatic grade and stage, and

    compensated liver disease.

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    Therapy is not without risk, and somecases may not be recommended

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    Before therapy is initiated.

    Quantitative HCV testing => to obtain

    baseline information on the viral load

    Genotyping => to deside response to

    therapy and duration of therapy

    Liver biopsy => to determine histologic

    grade and stage and to guide therapy

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    Treatment response is monitored according to

    the following terminology:

    Early virologic response (EVR): patient who experiences atleast 2-log reduction in viral load by the 12th week oftreatment

    End-of-treatment response (ETR): patient with no detectableviral load at the end of treatment

    Sustained virologic response (SVR): patient with nodetectable viral load at the conclusion of therapy and 6months later

    Relapser: patient who responds to therapy but whose viralload becomes detectable at the conclusion of therapy

    Nonresponder: patient with a stable viral load during the

    course of therapy Partial responder: patient with t least a 2-log reduction in

    viral load but who never has undetectable viral levels.

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    Nonpharmacology therapy

    Patients should be encourage to maintain

    good overall health, stop smoking, and

    avoid alcohol and illicit drug.

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    Pharmacology Therapy

    The current standard treatment => combinationtherapy of a once-weekly of PEG-IFN and daily

    oral dose ribavirin.

    Therapy is optimized based on genotype, patient

    weight, and response to therapy.

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    Algoritma therapy HCV

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    Interferon.

    PEG-IFN yang efektif dan aman.

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    Ribavirin.

    Ineffective as a monotherapy

    Dosed based on weight

    Side effect nya banyak Inevitable effect: ANEMIA

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    Alternative treatment.

    VX-950

    valopcitabine

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    In special population

    Patient withnormal ALTs

    Patients withdecompensated

    cirrhosis

    Relapsedpatients

    nonresponders

    Accidentalneedle-stickexposures

    Intravenous-drug users

    alcoholismEnd-stage renal

    disease

    HIV infection Children

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    Kasus

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    Riwayat pengobatan pasien

    Pria Caucasian (43 thn)

    Hepatitis B

    thn 1996

    150mg/hari

    Before

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    150mg/hari

    HBIg

    Uji Lab bulan Maret 2000

    Uji

    LaboratoriumHasil Normal

    ALT 503 IU/L 10-40 U/L

    AST 366 IU/L 14-20 U/L

    ALP 322 IU/L 25-100 U/L

    Bilirubin 52 mol/L 5-17mol/L

    albumin 43 g/L 35-48 gr/L

    Kreatinin 147 mol/L 80-115 mol/L

    WBC 3.5 4,5-10,5 x 103/sel/mm3

    platelets 97 140-400 x 103/mm3

    HBV DNA titre >40 juta negatif

    4 minggu kemudianpasien mengalami graft failure with ascites & jaundice

    Uji

    LaboratoriumHasil

    ALT 488 IU/L

    AST 557 IU/L

    ALP 260 IU/L

    Bilirubin 260 mol/L

    Albumin 33 g/L

    Kreatinin 160 mol/L

    WBC 2,3

    Platelets 134

    HBV DNA titre 9 juta

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    150mg/hari

    HBIg

    100mg/hari 10 mg/hari HBIg

    Kurva waktu pengobatan vs Bilirubin, ALT, HBV DNA

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    Lamivudine treatment HIV dan HBV

    HBIg memberikan imunitas pasif pada infeksi

    hepatitis B

    Adefovir pengobatan hepatitis B kronik

    Obat yang diberikan

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    DTP Keterangan

    Penggunaan Obat tanpaIndikasi

    Tidak Ada

    Adanya Indikasi dan Tidak

    Diterapi

    Tidak Ada

    Pemilihan Obat Tidak Tepat Tidak Ada

    Dosis kurang atau lebihDosis berlebih (sebelum transplantasi hati)menurut Dipiro dosis treatment Hepatitis B

    100mg/hari

    Interval dan Lama Pemberian

    Tidak Tepat

    Pada pengobatan tidak diketahui berapa

    lama penggunaan obat

    ESO Tidak Ada

    Interaksi Obat Tidak Ada

    DTP

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    Monitoring Pasien

    1Monitoring terhadap data-data laboratorium

    ( bilirubin, ALT, dan HBV DNA )

    2

    Monitoring efek samping obat yang mungkin timbul

    selama pengobatan

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    Matur Nuwun..............